Public Health Ethics

At its core, public health is concerned with promoting and protecting
the health of
populations,[1]
broadly understood. Collective
interventions in service of population health often involve or require
government action. In the United States, for example, the Centers for
Disease Control and Prevention, the Food and Drug Administration, the
Environmental Protection Agency and the Consumer Protection Agency are
in part or in whole public health agencies. All nations and most
states or provinces and municipalities have health departments whose
functions include everything from the inspection of commercial food
service to the collection and use of epidemiological data for
population surveillance of disease. Collective action to promote and
protect population health also occurs at the global level, as
exemplified by the activities of the World Health Organization. Public
health ethics deals primarily with the moral foundations and
justifications for public health, the various ethical challenges
raised by limited resources for promoting health, and real or
perceived tensions between collective benefits and individual
liberty.

One view of public health ethics regards the moral foundation of
public health as an injunction to maximize welfare, and therefore
health as a component of welfare (Powers & Faden 2006). This view
frames the core moral challenge of public health as balancing
individual liberties with the advancement of good health outcomes.
Consider, for example, how liberties are treated in government
policies that fluoridate municipal drinking water or compel people
with active, infectious tuberculosis to be treated.

An alternative view of public health ethics characterizes the moral
foundation of public health as social justice. While balancing
individuals' liberties with promoting social goods is one area of
concern, it is embedded within a broader commitment to secure a
sufficient level of health for all and to narrow unjust inequalities
(Powers & Faden,
2006).[2],[3]
Thus, another important area of concern is
the balancing of this commitment with the injunction to maximize good
aggregate or collective health outcomes. Understood this way, public
health ethics has deep moral connections to broader questions of
social justice, poverty, and systematic disadvantage.

Against the backdrop of these two normative approaches, this paper
proceeds as follows: Section 1 lays out some of the distinctive
challenges of public health ethics. Section 2 discusses different
justifications for public health interventions, including the role of
paternalism and how it bears on the permissibility of public health
interventions. Also discussed in Section 2 are broader questions of
democratic legitimacy. Section 3 focuses on questions of justice and
fairness in public health ethics. Finally, Section 4 discusses global
justice as it intersects with public health. Overall, this entry
strives to provide a general lay of the land of the central issues
that drive public health ethics, with a particular focus on questions
of justice and
fairness.[4]

There is no standard way of organizing the ethics of clinical
practice, public health and biomedical science. These distinctive
fields are often presented as focal areas that fall under the broader,
umbrella term of bioethics, but sometimes bioethics is presented as
the equivalent of medical ethics or in contrast to public health and
population-level bioethics. Whichever approach is preferred, a key
question remains: what distinguishes public health ethics from the
ethics of clinical practice or the ethics of biomedical science? The
answer lies in the distinctive nature of public health. Public health
has four characteristics that provide much of the subject matter for
public health ethics: (1) it is a public or collective good; (2) its
promotion involves a particular focus on prevention; (3) its promotion
often entails government action; and (4) it involves an intrinsic
outcome-orientation.

First, in public health the object of concern is populations, not
individuals. Public health is, by its very nature, a public, communal
good, where the benefits to one person cannot readily be individuated
from those to another, though its burdens and benefits often appear to
fall unevenly on different sub-groups of the population. This raises a
particular set of justificatory challenges public health ethics has to
address: who is public health good for? Whose health are we concerned
with, and what sacrifices is it acceptable to ask of individuals in
order to achieve it? Is there a difference between public health and
population health? And why is public health a good worth promoting?
Any answer to these questions has to take account of the fact that
public health measures are often based on prospective benefits,
not immediately securable
benefits.[5]

Second, promoting public health involves a high degree of commitment
to the prevention of disease and injury. However, although much of the
discussion surrounding public health focuses primarily on this
preventive aspect, public health agencies and services also involve
diagnosing and treating illnesses, with all the attendant clinical
services that those activities require. Indeed, increasingly national
health systems are understood to include both preventive functions and
the delivery of personal medical services. Often, these functions and
services are integrated under a common political or administrative
structure. Depending on the specific context in which population
health is to be improved, separating public health services and
functions from personal medical care services and functions may or may
not make sense. That said, policies and programs whose aim is to
prevent illness and injury are paradigmatically the territory of
public health. Certainly, no other social institution is generally
recognized as so clearly having this remit.

Public health's commitment to prevention carries with it particular
moral challenges. Eliminating or mitigating a harm that already exists
is sometimes viewed as being of greater moral importance - or simply
as more immediately motivating action - than long-term strategies to
prevent a harm from materializing. Although in recent years there is
arguably more emphasis on prevention in health policy, preventive
public health interventions continue to receive less funding and
public support than medical treatments. For example, despite the
increasing focus on wellness in public policy and the
workplace,[6] both
policy makers and the public still tend to place a higher priority on
ensuring that heart patients have access to surgery and medications
than on programs to prevent heart disease through diet and
exercise. Another factor that can result in prioritizing cures over
prevention is that although the costs and burdens of preventive
interventions occur largely in the present, the benefits of successful
preventive interventions often occur in the future, and usually only
to some members of the population whose identities cannot be predicted
in advance and whose numbers can only be estimated
probabilistically.[7]
Thus, prevention policies and programs
raise questions about how we should think about statistical and
unidentified lives and persons, and whether health gains in the future
should be treated as worth less than health gains in the present. In
some cases, the beneficiaries of preventive interventions are members
of future generations, complicating the moral picture even
further.

Third, as noted previously, achieving good public health results
frequently requires government action: many public health measures are
coercive or are otherwise backed by the force of law. Public health is
focused on regulation and public policy, and relies less often on
individual actions and services. In this as in all other areas of
official state action, we therefore have to address tensions among
justice, security, and the scope of legal restrictions and
regulations. This adds to the peculiarity of the justificatory
questions surrounding public health: the exercise of public authority
and the imposition of public sanctions and penalties in an area as
deeply personal as an individual's health choices require strong
justification. The same questions of trade-off between personal
freedom and collective action that arise in the political arena
generally thus also arise for public health. It is in this context
that concerns about paternalism typically emerge.

Fourth, public health has a definite consequentialist
orientation. Promoting public health means seeking to avoid bad health
outcomes and advance good ones. As noted at the outset, in some
discussions of public health ethics, this outcome-orientation is
viewed as the moral justification and foundation of public health and,
as with all consequentialist schemes, is presented as needing to be
constrained by attention to deontological concerns such as rights, and
by attention to justice-related concerns such as the fair distribution
of burdens (Childress et al. 2002; Kass 2001). While public
health ethics has to engage with the traditional problems raised by
its consequentialist commitments, for those who view social justice as
the moral foundation of public health, considerations of justice
provide the frame within which the moral implications of public
health's consequentialist orientation are addressed.

These four distinctive features provide public health ethics with its
basic structure and orientation. Under the first rubric, important
questions arise with regard to the scope of public health: who is the
“public?” The usual assumption is that the public is a
discrete unit that corresponds with state boundaries: a single
country's population. But in a global world, that assumption is not
always plausible for various reasons. Communicable diseases have a way
of ignoring national boundaries, and preventive measures in one
country may be futile if other countries do not follow
suit.[8] Moreover,
the statist focus is not always readily justifiable: insofar as
diseases cross borders, should public health interventions do the
same? Further questions about justice and equity across borders also
arise: do wealthier countries and wealthier individuals have
obligations to attend to the public health of less fortunate others?
These questions will be discussed further in section IV, below.

Depending on the particular health challenge we are concerned with,
the public in question can be more local or more global than a single
country's population. National boundaries are relevant because
policies and regulations are usually set by individual countries, and
vary from country to country. They are also relevant for reasons
having to do with government control: countries report their data
about communicable disease outbreaks, burden of disease, and other
health indicators to global institutions such as the World Health
Organization (WHO) on a voluntary basis. Although International Health
Regulations to which 196 countries (WHO 2014) are signatories provide
an international structure for global public health, as with much
international law and regulation, enforcement mechanisms are weak. It
is not clear what the moral implications of these practical
limitations should be for public health. The structure of the problem
is similar to environmental challenges such as air pollution and
global warming: determinants of ill health are not restricted by
national boundaries, and we are all ultimately connected to each
other's health status, at least in some ways. But more importantly,
citizens in the developed world are arguably causally connected to
some health deprivations in the developing world, for example by
upholding restrictions on the production and distribution of generics
that hinder the containment of easily treatable diseases in poor
countries (Pogge 2002; Grover, Citro, Mankad & Lander 2012). This
gives public health, and therefore public health ethics, a special and
very interesting location vis-à-vis discussions of global
justice, our duties to the distant poor, and the need for global
cooperation to address common problems (Holland 2007).

Another issue that comes up in this connection is the following: are
“public” and “population” interchangeable
terms to designate the entity whose health we are concerned with? Is
there a significant conceptual difference, a difference in moral
valence, or a difference in attitude and orientation between public
health ethics on the one hand, and population-level health ethics on
the other? The literature presents three general ways of denoting the
object of public health: community, the public, and populations. In
one sense, the most morally laden manner of designating those who are
subject to, and benefit from, public health measures, is to think
about them as a community (Beauchamp & Steinbock 1999). Reference
to “community” implies a cohesive group, usually with a
shared language, culture, history, and geographical
location. Characterizing the concern of public health as being the
health of the community renders more natural (and possibly more
plausible) appeal to the common good as a way of justifying public
health interventions. Reference to “the public” shares
some of those same features but tends to be less morally laden. This
is in part because “the public” is somewhat more anonymous
than “the community” and does not necessarily signal a
tight cultural connection. Rather, it connotes a relatively discrete
unit with some common institutions and usually a shared political
life. Thus, references to the public as well as to the community may
encourage the perception that the good we are seeking to advance is
that of a geographically bounded unit, with community connoting
stronger cultural associations, and public connoting some kind of
official political unit such as a state or a country.

Characterizing the health we are trying to advance as that of
populations, by contrast, may minimize the implication that special
shared features or characteristics are needed in order for a group of
individuals to constitute a collective unit whose health can be of
concern. Because of that, it may lend itself more readily to an
internationalist, less inward-looking orientation: any population,
regardless of nationality or geographic location, has health interests
that ought to be attended to and advanced (Wikler & Brock
2007). Populations can be more local or more global than a community
or the public. This way of speaking also may dilute the emphasis on
national borders as a way of delineating the scope of concern and
provides more flexibility in the object of concern for public
health. In much the same way, discussion of global health, as opposed
to international health, is seen as helpful in emphasizing a focus on
the health needs of all, as opposed to a focus on international
cooperation and the health needs of peoples in countries other than
one's own.

This is not, of course, to say that those who prefer the term
“public health” to “population health” do not
share a global orientation. Indeed, the World Health Organization is
generally referred to as a global public health institution, and those
who work to promote health transnationally are referred to as public
health and not population health professionals. Indeed, although some
see a substantive conceptual divergence in ways of thinking about
whose health is to be protected and promoted, others see no conflict,
at least between the concepts of public health and population
health. For example, the Nuffield Council on Bioethics uses the term
“population health” to refer to the collective state of
health of members of a population and the term “public
health” to refer to efforts made to improve the political,
regulatory and economic environments that affect prospects for
health. So understood, the object of public health is the improvement
of population health (Nuffield Council on Bioethics 2007, p. XV).

Another conceptual challenge central to public health ethics is how to
think about public health or population health as a public good. Is
the health of the public or of a population a good in its own right,
or can it meaningfully be understood only as an aggregation of the
welfare interests secured for each individual that comprises the
population? Is public health a good that nations and global
institutions can rightly seek with the same justificatory structures
and limitations with which they seek national security and world
peace, or is it somehow a more limited or different kind of political
construct?

Common to the second, third and fourth features of public health is
the question of how broadly or narrowly to understand what public
health entails (Powers & Faden 2006). Given a widening
understanding of health and the factors affecting prospects for
population health, public health can be viewed as being so expansive
as to have no meaningful institutional, disciplinary or social
boundaries. Everything from crime, war and natural disasters; to
population genetics, environmental hazards, marketing and other
corporate practices; to political oppression, income inequality and
individual behavior has been claimed under the rubric of public
health. Part of what makes each of these diverse things of concern is
their impact on health, and in that sense they are all public health
problems. A central role of public health, grounded in social justice,
is to bring attention to all aspects of the social or natural world
that exert a significant impact on the preservation or promotion of
health, and not only those that can be effected through traditional
public health measures or means.

At the same time, however, health is only one dimension of human
well-being. Calling attention to the devastating impact on the health
of women of Taliban rule is important, but it should not be confused
with reducing the injustices of the oppression of women to its health
effects. The assault of such oppression on personal security,
self-determination and respect is of independent moral
concern. Similarly, while reducing violence is critical to population
health, that does not mean that law enforcement, the criminal justice
system, diplomacy and international relations should be considered
tools of public health. Whether and under what conditions it is
advantageous to frame or re-frame a social problem in public health
terms is morally complex. For example, taking a public health rather
than criminal justice orientation to gun violence or drug abuse can
sometimes contribute to defusing tensions, decreasing negative
impacts on racial or other minority groups, and leading to better overall
outcomes (Dorfman & Wallack 2009).

Because so many of the determinants of the different dimensions of
well-being overlap and reinforce one another, it is not surprising
that different social institutions and professional communities share
common concerns and priorities, nor should it be expected that public
policies rest on only one moral consideration like health or
security.

The flip side of this observation is that public health has an
obligation to evaluate the impact of its policies and practices on
human well-being broadly and not only on health. Guaranteed access to
basic health services can improve health, but just as importantly, it
can provide people with a sense of social worth and eliminate the
insecurity of being unable to provide for loved ones in times of
crisis. Similarly, screening programs for sexually transmitted
infections may improve health but, depending on features of the
programs and the contexts in which they are implemented, they may
result in social disrespect, decreased personal security and
constraints on personal behavior.

The overlapping of effects and justifications is particularly clear in
prevention. Immunization, water fluoridation, anti-smoking campaigns
and motorcycle helmet laws are all paradigmatic preventive public
health interventions. At the same time, however, interventions
generally outside the purview of public health institutions and
professionals such as early childhood education, income supports,
literacy initiatives for girls and safe housing programs all can be
effective in preventing illness and injury. In some cases, such
interventions may be more effective and efficient in achieving health
gains than paradigmatic public health programs. Morally responsible
public health policy requires attentiveness to the multiple
determinants of health. This requirement does not signal that public
health has no boundaries. Rather, public health has a unique
relationship of stewardship to one dimension of well-being, health,
and to the particular determinants that have a special strategic
significance for health. Some of those determinants are the classic
focus of public health such as infectious disease control and the
securing of safe food, water, and essential medications. However,
exercising that stewardship requires responsiveness to the best
available evidence about all the determinants, across the landscape of
an interconnected social structure, that have a special strategic
relation to health, including those outside the conventional remits of
public health agencies and authorities. Policies governing education,
foreign assistance, agriculture, and the environment can all have
significant impact on health, just as health policies can have impact
on international relations and national and global
economies. Providing public health arguments in defense of particular
environmental or educational policies, and recognizing that such
policies can have profound effects on health, simply recognizes the
complex interweaving of the multiple dimensions of human welfare.

One worry raised by this interconnectedness across spheres of social
life and policy is that classifying something as a public health
matter could be an effective way of taking it out of the realm of
legitimate discussion. If the goal of protecting health is seen as
clearly good, government actions aimed at securing health may be less
scrutinized than actions aimed at more controversial ends, leaving
public health officials with too much power and too little democratic
accountability. As a practical matter, however, these concerns may not
be realistic. Although data on this point are hard to come by, it is
likely that the reverse is true: public health agencies and workers
are more likely to have insufficient political power, authority and
resources at their disposal to achieve important and pressing goals
than to wield too much. It is not usually individuals' civil rights to
which public health interventions stand in opposition, but rather
private, corporate economic interests such as the tobacco industry,
the meat and dairy industry, and so on. Nonetheless, it is worth
raising these worries at least to keep them in view as a possible
issue for public health ethics to address.

Even if the worry that expanding the classification of something as a
public health matter in some way threatens civil liberties is nothing
more than fear-mongering, the breadth of what falls under public
health may raise concerns about democratic legitimacy. Insofar as
health authorities have a public mandate to advance health, is it
therefore appropriate for them to hue to strict guidelines as to what
they can undertake in the name of public health based, at least in
part, on the expressed or revealed preferences or values of those
within their reach? Under what conditions are measures such as public
health surveillance and the banning of certain food materials properly
considered to be overreaching by public health authorities, and
therefore to constitute a lack of adherence to their
democratically-given mandate? Public health ethics has to give serious
consideration to the question: how exactly should the mandate of
public health authorities be specified such that they do not run afoul
of the requirements of legitimacy in a democratic political
system?

Particularly when government institutions are charged with promoting
population health, a task of public health ethics is determining
self-imposed limitations and restrictions on what can reasonably come
under the auspices of public health authorities, for reasons having to
do with concerns about individual liberty, about privacy and
paternalism, about democratic process, and about the place of health
in relation to other aspects of human well-being. Thus, public health
ethics also has to engage more traditional philosophical questions
about the scope of privacy, the reach of public policy, and the limits
and legitimacy of government intervention for the public good. These
issues are addressed next, in Section 2. Moreover, scarcity and
priority setting always loom large in the context of public health,
giving rise to a number of equity, justice, and fairness concerns. As
already noted, these issues are especially acute with regard to global
health. Justice and priority setting issues will be addressed in
greater detail in Section 3.

Public health draws its foundational legitimacy from the essential and
direct role that health plays in human flourishing, whether that role
is understood ultimately in terms of maximizing health or of promoting
health in order to advance social justice. This general justification
is sometimes too broad, however, to provide sufficient moral warrant
for specific public health policies and institutions, especially when,
as is so often the case, these policies and institutions are
implemented by the state and affect the liberty or privacy of
corporate or individual persons. This section puts forward five
justifications for public health interventions.

Two observations are worth making at the outset. First, public health
policies are rarely defended by only one reason. Usually a mixed set
of justifications can plausibly be provided. For example, tax policies
intended to decrease cigarette consumption can be defended both by
appeal to paternalism and by appeal to reducing the harms of second
hand smoke to children in the home and in automobiles. Second, the
impact of public health policies is often not uniform across all the
individuals affected by the policy, and thus different justifications
are sometimes put forward specific to these different people. This
complexity is unavoidable, since it results from the nature of public
health: the focus of public health is population health, but
populations are rarely internally uniform with regard to all features
that are morally relevant to any particular policy. Some people may
stand to benefit from the policy while others may not. Moreover, in
line with concerns about democratic legitimacy and state
over-reaching, some members of the population may support the policy
while others may object. Consider, for example, a New York City policy
prohibiting restaurants from serving sugar-sweetened beverages over 16
ounces that was eventually struck down by the courts. Public opinion
polling suggests that while more New Yorkers opposed the policy than
supported it, the level of opposition varied from one borough of the
city to another (Grynbaum & Connelly 8/21/2012; New York Times
8/21/2012).

The first three justifications for public health policies - overall
benefit, collective action and efficiency, and fairness - speak
specifically to the context in which some members of the affected
population do not directly benefit from the policy or object to
it. The next two justifications appeal to the significance of harm,
both to others and to oneself. They apply more specifically to
traditional concerns about balancing respect for liberty with
advancing health and are more prevalent in the public health ethics
literature than the previous three. In the fourth justification, the
argument is from a relatively uncontroversial Millian harm principle,
and in the fifth justification, from somewhat more tendentious
paternalistic principles.

Depending on the specifics of the public health policy, any number of
these justifications may be applicable, and they are generally used to
best effect in combination. Section 2 closes with a look at the limits
of frameworks that focus disproportionately on liberty considerations
of the sort addressed in 2.4 and 2.5 and on the importance of
considering the range of possible moral justifications in analyzing
public health policies.

Ultimately, we all benefit from having public health interventions,
and from having trusted regulatory agencies such as the Centers for
Disease Control and Prevention (CDC) or the Food and Drug
Administration (FDA) make decisions about such interventions and their
reach. All things considered, having public health regulation is
better than not having it. Public health decisions made on the basis
of overall statistics and demographic trends are ultimately better for
each one of us, even if particular interventions may not directly
benefit some of us. Thus, the task of public health ethics is not
necessarily to justify each particular intervention directly. Rather,
public health interventions in general, as long as they stay within
certain pre-established parameters, can be justified in the same way a
market economy, the institution of private property, or other
similarly broad and useful conventions that involve some coercive
action but also enable individuals to access greater benefits can be
justified: when properly regulated and managed, their existence is by
and large better than their absence for everyone. So structured, the
justification for particular public health interventions,
requirements, or restrictions is derivative of or parasitic on a
higher level
justification.[9]
This argumentative strategy has a lot of
appeal, particularly as a way of justifying the existence of
regulatory government agencies such as the FDA or CDC. However, it is
ultimately insufficient on its own and needs to be supplemented by
other kinds of ethical arguments, since it does not provide the basis
for the parameters themselves, or for ethical oversight or scrutiny
with regards to the particular decisions such agencies
take.[10]

A related justification views health as a public good the pursuit of
which is not possible without ground rules for coordinated action and
near-universal participation. Thus, public health is viewed as having
the structure of a coordination or collective efficiency problem. If
one person (or at least, a sufficient number of such persons) decides
to go when the traffic light is red and stop when the traffic light is
green, it does not matter that everyone else is following the rules:
this person will disrupt the smooth functioning of the system, with
potentially dangerous results. Similarly, if one person (or a
sufficient critical mass of such persons) decides not to abide by a
public health regulation because the regulation does not directly
benefit her or she otherwise objects, the ramifications will likely be
felt by others in her environment and
beyond.[11]
Everybody has to participate because, failing their involvement,
neither they nor anyone else can reap the benefit of a healthy
society.

In many public health contexts, the only feasible or acceptably
efficient way to implement a policy affects the entire population,
leaving no or only very burdensome options open to individual
non-cooperation. Perhaps the most celebrated such example is water
fluoridation, but all safety regulations affecting food and drug
supply and consumer products share this character, as do many
environmental and occupational health standards. Here collective
efficiency considerations loom large. Although we want healthy
environments and products, individuals are simply not positioned to
make independent decisions about the impact on health and safety of
their environment and of the hundreds of thousands of products
available in the modern market place. Ceding this function to
government institutions staffed with health experts is prudent and
essential to general welfare and social justice in the same respect as
ceding protection of our interests in personal physical security to
government institutions staffed with law enforcement and national
defense experts is prudent and essential to general welfare (Mill
1869).

Collective efficiency arguments rely on claims about the sheer number
and technical complexity of the decisions that need to be made to
protect health in the environment and in the market place, as well as
the indivisible character of responses to some health threats. These
arguments are buttressed by claims about the cognitive limitations and
bounded rationality of individual human decision makers, and by the
disproportionate political power of corporate interests and the
practices they use to manipulate and exploit our cognitive weaknesses
against our health interests (Ubel 2009).

Yet another appeal that can be used to defend certain public health
interventions that impose unequal burdens on different members of a
population relies on considerations of fairness. The basic premise of
this line of argument would be that burdens should be roughly
equivalent for everyone. This justifies taxing different income
brackets at different rates. The same could be said for certain public
health “burdens,” understood as both the burdens of
disease and disability and the burdens of public health
interventions. Based on considerations such as a particular group's
likelihood to contract a certain disease, and their overall health
status, other parts of the population can legitimately be asked to
“contribute,” as it were, in order to make the
distribution of disease burdens more equitable. For example, part of
the rationale for requiring child immunization prior to enrollment in
school is that this is a way to ensure that low-income children, who
are generally less healthy than other children, have access to the
needed vaccines (Orenstein & Hinman 1999; Feudtner & Marcuse
2001). Perhaps a more pertinent example is Japan's seasonal influenza
immunization policy, between 1962 and 1994 where children were
immunized against influenza explicitly in order to protect the
elderly, for whom contracting seasonal flu is more likely to be fatal,
and immunization more likely to be burdensome (Reichert et
al. 2001; Sugaya 2014). Yet another example of public health
interventions that appear to be guided by this justification is
rubella vaccination of children for the sake of pregnant women and
their fetuses (Miller et al. 1997; ACIP 2010 in Other Internet
Resources). This reasoning can help explain why individuals are
sometimes asked to bear public health burdens that do not directly
benefit them. However, as with the tax case, the question of how far
we can go in redistributing health-related burdens will likely
continue to plague any proponent of this justificatory
strategy. Moreover, questions about the plausibility of viewing
health-related burdens as subject to distribution in this manner may
also arise.

Likely no classic philosophical work is cited more often in the public
health ethics literature than John Stuart Mill's essay “On
Liberty” (Mill 1869). In that essay, Mill defends what has come
to be called the harm principle, which has been interpreted as holding
that the only justification for interfering with the liberty of an
individual, against her will, is to prevent harm to others. The harm
principle is relied upon to justify various infectious disease control
interventions including quarantine, isolation, and compulsory
treatment. In liberal democracies, the harm principle is often viewed
as the most compelling justification for public health policies that
interfere with individual liberty. For example, a prominent view in
the United States is that it was not until the public became persuaded
of the harmful effects of “second hand smoke” that the
first significant intrusion into smoking practices—the banning
of smoking in public places—became politically possible. Perhaps
because of the principle's broad persuasiveness, it is not uncommon to
see appeals made about harm to others in less than obvious
contexts. Defenders of compulsory motorcycle helmet laws, for example,
argued that the serious head injuries sustained by unprotected
cyclists diverted emergency room personnel and resources, thus harming
other patients (Jones & Bayer 2007). The harm principle has been
interpreted to include credible threat of significant economic harm to
others as well as physical harm. Returning again to smoking policy,
various restrictions on the behavior of smokers have been justified by
appeal to the financial burden on the health care system of caring for
smoking-related
illnesses.[12]

As with all such principles, questions remain about its
specification. How significant must the threat of harm be, with regard
to both its likelihood and magnitude?[13] Are
physical harms to the health of others to be weighted more than
economic harms or other setbacks to interests? Whether interpreted
narrowly or broadly, there are limits to the public health cases that
can plausibly be addressed by the harm principle. Moreover, in the
context of commitments to social justice and general welfare, and the
other justifications described above, too exclusive a focus on the
harm principle can undermine otherwise justifiable government mandates
and regulation. It is undeniable that individuals have much broader
and more multi-dimensional interests than narrowly self-directed
physical ones, and in that sense, it is not unreasonable to have a
fairly expansive understanding of “harm” in a public
health context. However, adherence to the—admittedly somewhat
artificial—heuristic of construing individuals' interests as
exclusively their self-regarding ones for purposes of determining what
sacrifices they may be asked to make is an important way of ensuring
checks on potential abuses.

Because the impact of J.S. Mill on public health ethics cannot be
overstated, it is important to recognize that Mill does not hold that
in the formulation of public policies all liberty interests enjoy an
equal presumption in their favor. Mill draws a distinction between
interests that are so important that they are immune from state
interference, interests that enjoy a presumption in favor of liberty,
and interests that enjoy no such presumption. It is presumably the
second kind of liberty interest where the harm principle figures
prominently (Powers, Faden and Saghai 2012). Moreover, what many
understand to be core to Mill's view, that individuals are generally
best positioned to know what is in their own best interests, is
increasingly being challenged (Conly 2014; Sunstein 2013).

Not surprisingly, paternalism—understood classically as
interfering with the liberty of action of a person, against her will,
to protect or promote her welfare—is as controversial in public
health policy as the harm principle is uncontroversial (Dworkin 2005;
Feinberg 1986). Few public health interventions are justified
exclusively or even primarily on unmediated, classic paternalistic
grounds, although many more public health programs may have
paternalistic effects. By contrast, other classes of arguments that
are sometimes described as paternalistic, including soft paternalism,
weak paternalism, and libertarian paternalism, are evoked more
frequently.

Soft and weak paternalism are usually interpreted as interchangeable,
though they have sometimes been taken to denote different concepts
(Dworkin 2005). A common interpretation defines this kind of
paternalism as interferences with choices that are compromised with
regard to voluntariness or autonomy. Though a person might voice or
hold a preference different from the one that is sought for her, her
preference is not entitled to robust respect if it is formed under
conditions that significantly compromise its autonomy or
voluntariness, such as cognitive disability or immaturity and, in very
limited cases, ignorance or false
beliefs.[14]
Adaptive preferences are also considered compromised with regards to
autonomy: sometimes, individuals modify their preferences in order to
be able to adapt to difficult, unjust, or undesirable
circumstances.[15]
Such preferences also do not have the
same standing as preferences formed under just or normal background
conditions and are therefore viewed as subject to interference.

It is important to note that in all these cases, justified
interference would be based on a finding of significant compromise of autonomy or rationality in the formation or continued holding of
particular preferences. This should not be confused with interference
based on the content of the preferences. Only the former would be
justifiable under soft or weak paternalism, whereas the latter would
constitute true or strong paternalism. As always, the demarcations are
not as clear in practice as they are in theory - the content of
preferences is often precisely what is appealed to in illustrating
that a particular preference is compromised - but by and large, what
distinguishes soft paternalism from strong paternalism is the
requirement that the decision or preference be fundamentally
compromised, and not simply that it be mistaken or ignorant. This
principled distinction remains important not least because it reflects
a difference in approach or attitude: in the case of strong
paternalism, the interference is based on the content of a preference
not reflecting what is ostensibly in the preference holder's
interest.[16] In
the case of soft or weak paternalism, persons might hold all manner of
preferences not in their best interest that are nonetheless not
justifiably interfered with because the relevant compromising
conditions do not obtain. In public health policy, soft paternalism
has been evoked to justify interventions that limit the ability of
adolescents to act on preferences for alcohol, drugs, sexual activity
and driving.

In recent years, public health policy and liberal governments have
increasingly looked to interventions called 'nudges' to influence
health behaviors in desirable directions. Nudges, understood typically
as interventions in choice architecture, are the focus of libertarian
paternalism. Libertarian paternalism defends interventions by planners
(such as public health authorities) in the environmental architecture
in which individuals decide and act in order to make it easier for
people to behave in ways that are in their best interests (including
their health), provided two conditions are satisfied (Thaler
&Sunstein 2003; Thaler & Sunstein 2008). First, individuals
are steered by these interventions in ways that make them better off,
as judged by themselves. Thus, in libertarian paternalism there is no
attempt to contravene the will of individuals, in contrast to what
some hold to be a necessary feature of paternalism. Second, the
interventions must not overly burden individuals who want to exercise
their freedom in ways that run counter to welfare. In this sense,
libertarian paternalism claims to be liberty-preserving, hence
libertarian.

A key conceptual question about paternalism is whether the
interference with individual liberty must be against the person's will
(Beauchamp 2010). If this feature is a necessary condition of
paternalism, then libertarian paternalism is inappropriately
titled. From the standpoint of public health ethics, however, whether
libertarian paternalism is appropriately titled is less important than
any moral issues it raises and how it is justified. There is a growing
literature on the ethics of 'nudges,' much of it focusing on health
(Saghai 2013a; Saghai 2013b; Quigley 2013; Hollands et al.
2013).

Libertarian paternalism is grounded in the extensive empirical
literature in cognitive psychology and the decision sciences that
support claims about our cognitive limitations, bounded rationality
and weakness of will. Although it raises challenging epistemic and
political questions about how planners know what individuals judge is
in their interest in specific policy contexts, libertarian paternalism
may be well suited to public health contexts in which there is broad
public consensus in favor of health-promoting behaviors such as eating
more fruits and vegetables or getting more exercise, and a general
recognition that it is difficult for people to act as prudentially as
they would like. Thaler and Sunstein suggest, for example, that salads
rather than French fries could be made the default “side”
on restaurant menus, with diners free to request fries if that remains
their preference. At the same time, libertarian paternalism has been
criticized for failing to take account of the manipulative effects on
choice of some market place forces. It has also been seen as too
restrictive in its conditions (and therefore too weak) to be
applicable or adequate for many public health contexts (Nuffield
Council on Bioethics 2007; Ubel 2009).

Part of the appeal of libertarian paternalism in public health policy
is that, at least in certain contexts, it appears to sidestep or in
some cases resolve the tension between liberty and health. This
tension takes center stage in some analyses of the ethics of public
health, as when public health policies are placed on autonomy-limiting
continua and the fourth and fifth justifications dominate the
analysis. An influential such continuum is the Nuffield Council's
“intervention ladder” (Nuffield Council on Bioethics
2007), which is presented as a way of thinking about the acceptability
and justification of public health policies. The ladder is anchored at
one end by what is presented as the least intrusive option, doing
nothing, and at the other end by the what is presented as the most
intrusive option, eliminating choice altogether (as in compulsory
isolation). The Council makes plain that all rungs on the ladder,
including doing nothing, require justification and that the ladder is
to be taken only as a tool in the moral analysis of public health
policies. However, the structure of the ladder and its attendant
imagery reinforce the misleading view that balancing individual
liberties with achieving health benefits is the primary moral
challenge of public health while at the same time appearing to
emphasize ethical concerns about over-reaching the mission of public
health over ethical concerns about under-serving it.

Continua of this sort also oversimplify the complex impact of
interventions on choice and liberty and on relations between citizens
and the state. Incentives are not always less restrictive of choice
than disincentives, and health promotion campaigns, which are
generally ranked at or near the least intrusive end of the continuum,
are not always without significant moral concern. Ad campaigns that
are transparently sponsored by public health agencies to prevent
transmission of influenza by promoting personal infection control
practices or reduce obesity by encouraging exercise and healthy eating
do not raise the same moral issues as the embedding of anti-drug or
abstinence messages in the story lines of entertainment television
programming by these same authorities (FCC 2000; Forbes 2000 (Other
Internet Resources); Goodman 2006; Krauthammer 2000; Kurtz &
Waxman 2000). While the latter poses important questions about respect
for liberty, government over-reaching and democratic legitimacy, the
limited effectiveness of many ad campaigns raises important questions
about whether the state is under-serving its public health
mission. Moreover, in the case of public health problems like obesity,
a reliance on health promotion campaigns and other strategies focused
on influencing the behavior of individuals may fail to place
appropriate burden on the corporate interests and structural social
inequalities that arguably account for much of the problem. Thus,
depending on the circumstances, health promotion campaigns may be
unjust as well as ineffective (Buchanan 2008; Crawford 1977; Faden
1987; McLeroy, Bibeau, Steckler, & Glanz 1988).

An important task of public health ethics is not only to provide
different moral justifications, but also to critically examine their
relationship to one another in the context of particular public health
issues and activities so as to ensure a more complete moral picture of
what is at stake, and to point out where no sufficient justification
exists. In this way, public health ethics can play a more immediate
practical role in public life: by raising challenges to and providing
moral scrutiny of public health policies, it can contribute to
creating an environment of accountability where both abuses and
deficiencies are less likely. Thus, in addition to its intellectual
significance, public health ethics can be an important element in the
scheme of checks and balances that help keep public health authorities
from overreaching or under-serving their mission.

Whether social justice is viewed as a side constraint on the
beneficence-based foundation of public health, or as foundational in
its own right, there is broad agreement that a commitment to improving
the health of those who are systematically disadvantaged is as
constitutive of public health as is the commitment to promote health
generally (Powers & Faden 2006, Institute of Medicine (USA) 2003;
Thomas, Sage, Dillenberg & Guillory 2002; Nuffield Council on
Bioethics 2007; Kass 2001; Venkatapuram 2011; Gostin 2012).

In this regard, there is an intimate connection between public health
and the field of health and human rights (Mann et al. 1994;
Mann 1996; Beyrer et al. 2007; Beyrer & Pizer 2007;
Tasioulas & Vayena 2014; Tasioulas & Vayena 2015; Gostin &
Friedman 2013). Many in public health accept that there is a
fundamental right to health, as codified in the United Nations
Universal Declaration of Human Rights or otherwise, although there is
less agreement about the justification for such a right or what
precisely the right entails (General Assembly 1948). A key question
for public health ethics is on whom the duties generated by a right to
health fall. Because so many of these duties require collective action
of the sort described in Section 2, governments are obvious
candidates, but so, too, are other social institutions in the private
sector as well as those global in structure that bear on the right to
health. A failure on the part of these institutions to ensure the
social conditions necessary to achieve a sufficient level of health is
an injustice that on the view of many violates a basic human
right. Note that as a basic human right, the claims of the right to
health are not in any fundamental respect restricted to national
borders but rather fall on the human community, as a whole. Thus, as
we discuss later in this section, the extraordinary disparities in
life expectancy, child survival and health that distinguish those who
live in rich and poor countries constitute a profound injustice that
it is the duty of the global community to redress.

One task of public health ethics is to identify which inequalities in
health are the most egregious and thus which should be given high
priority in public health policy and practice. That the life
expectancy of some of world's poorest populations is over twenty-five
years less than the life expectancy of those living in some affluent
countries is a clear injustice of particular moral urgency. Not all
inequalities are so obviously egregious, however, and different
accounts of justice and of the relevance of individual responsibility
for health may yield different conclusions. Different approaches to
conceptualizing and measuring health inequalities have different
ethical implications (Eyal, Hurst, Norheim & Wikler 2012). On the
view that Powers and Faden defend (2006), social justice demands that,
insofar as possible, all children achieve a sufficient level of
health. Thus, inequalities in the health of children are a particular
moral concern. The health of children is dependent on the decisions
and actions of others and on features of the social structure over
which children have no control. The value of health to children thus
does not depend on what children can do for themselves, as it
sometimes does for adults. Moreover, the level of well-being
attainable in adulthood is in important respects conditioned by the
level of health achieved in childhood. Compromised health in childhood
has profound effects on health in adulthood, as well as on the
development of the cognitive skills necessary for reasoning and
self-determination.

When inequalities in health exist between socially dominant and
socially disadvantaged groups, they are all the more important because
they occur in conjunction with other disparities in well-being and
compound them (Wolff & de-Shalit 2007; Powers & Faden
2006). Reducing such inequalities are specific priorities in the
public health goals of national and international institutions
(Department of Health 2009; EuroHealthNet 2014 (Other Internet
Resources); Healthy People 2020 (2014, in Other Internet Resources);
Kettner & Ball 2004; WHO 2015). Whether through processes of
oppression, domination, or subordination, patterns of systematic
disadvantage associated with group membership are invidious and
profoundly unjust. They affect every dimension of well-being,
including health. In many contexts, poverty co-travels with the
systematic disadvantage associated with racism, sexism, and other
forms of denigrated group membership. However, even when it does not,
the dramatic differential in material resources, social influence and
social status that is the hallmark of severe poverty brings with it
systematic patterns of disadvantage that can be as difficult to escape
as those experienced by the most oppressed minority groups. Even when
these patterns are lessened, the life prospects of persons living in
severe poverty or in dominated groups often continue to be far below
that of others. A critical moral function of public health is to
vigilantly monitor the health of systematically disadvantaged groups
and intervene to reduce the inequalities so identified as aggressively
as possible. Keeping obligations to such groups at the forefront of
public health thinking can result in significant changes in public
health policy. For example, which countries should top the list for
the expansion of childhood vaccine programs from low to middle income
countries can be profoundly affected by how vigilant we are in keeping
systematic disadvantage squarely in mind (Shebaya, Sutherland, Levine
& Faden 2010).

One of the most difficult challenges for public health ethics emerges
when this important moral function conflicts with the injunction to
improve, if not maximize, aggregate or collective health
outcomes. Although the health of the world's most desperately poor can
in many cases be improved by extremely cost-efficient interventions
like basic childhood immunizations and vitamin supplementation,
reducing other unjust inequalities in health can consume significant
resources. For example, in the United States, infant mortality rates
are higher than in many other wealthy nations, and they are higher
still among poor and minority children. Some state public health
authorities have made reducing racial disparities in infant mortality
a top priority, accepting the view that redressing this unjust
inequality is an urgent moral concern. Other states have chosen the
goal of improving infant survival statistics overall, on grounds that
the same resources will produce greater aggregate health outcomes
while at the same time pointing to the special place that all children
should hold in public health policy (HRSA 2014 in Other Internet
Resources).

Still another challenge in social justice for public health ethics
emerges when the health needs of systematically disadvantaged groups
conflict with other dimensions of well-being as well as with
considerations of collective efficiency. Targeting a public health
program to poor and minority communities can sometimes both serve
social justice concerns and be efficient if, for example, the health
problem the intervention targets occurs disproportionately in these
groups. At the same time, however, if the health problem is itself
associated with stigma or shame, targeting the poor and minorities may
reinforce existing invidious stereotypes, thereby undermining another
critical concern of social justice, equality of social respect. In
such cases, public health authorities must decide whether a commitment
to social justice requires foregoing an efficient, targeted program in
favor of a relatively inefficient, universal program that also may
produce less improvement in health for the disadvantaged group (thus
failing to narrow unjust inequalities) in order to avoid exacerbating
existing disrespectful social attitudes.

As noted in Section 2, one of the structural features of public health
is that the individuals and groups affected by its policies and
programs are not uniformly benefited or burdened. When the burdens of
a policy fall heavily on those who are already disadvantaged, the
justificatory hurdle is particularly high. This concern is at the
heart of many environmental justice controversies such as the locating
of hazardous waste facilities and hazardous industries in low-income
communities and countries. Global efforts to prevent and contain
pandemic influenzas have also placed significant burdens on the
world's poor. For example, a principal strategy employed to prevent
avian influenza H5N1 from becoming a human pandemic is the destruction
of infected birds and the banning of household poultry in urban
settings. Many families and women affected by this policy relied on
their backyard poultry as their only disposable source of income and
have been economically devastated as a consequence. Without express
focus on the interests of disadvantaged people, the moral concerns
this policy raises, particularly in the absence of appropriate
compensation and alternative livelihood opportunities, might well go
unnoticed (Bellagio Working Group 2007 in Other Internet Resources;
Faden & Karron 2009; Uscher-Pines, Duggan, Garoon, Karron, &
Faden 2007).

Public health resources are always in short supply and priority
setting in public health policy and practice is always morally
challenging. Yet another important set of tasks for public health
ethics is working to ensure that considerations of justice are
prominent in the setting of public health priorities in health care
services and in prevention and health threat programming
(Norheim et al. 2014). In that regard, one focus for public
health ethics is evaluating the role that formal economic and decision
theory methods such as cost benefit, cost effectiveness and cost
utility analysis should play in public health, including the
continuing examination of the moral assumptions embedded in these
methods. Formal methods have been used to varying degrees by public
health authorities in numerous countries in such diverse contexts as
determining what risks should be regulated in environmental health and
injury prevention policy and in setting priorities for public health
goals and coverage decisions for health care systems. Embedded in
these methods are morally controversial assumptions. If the discount
rate applied to future financial costs and benefits is also applied to
future health benefits, preventive interventions are disvalued
relative to interventions whose health benefits occur in the present
(Schwappach 2007). Also problematic are “willingness to
pay” measures as proxies of the value of benefits or risk
reduction. Arguably, these measures reify the preferences of the
privileged and fail to provide sufficient moral justification when
risks materialize (Gafni 1991).

Some formal methods, including most notably cost-utility analysis,
rely on what are referred to as summary health measures in which
mortality and diverse morbidities are combined in a single metric such
as a quality-adjusted or disability-adjusted life year. These
measures, and the formal methods that employ them, sometimes rely on
assessments of what may be only vague individual preferences for
trade-offs between different states of health or different kinds of
benefits. Moreover, they make morally problematic assumptions
including, for example, whether to differentially value years saved in
different stages of life and how to disvalue specific
disabilities. Depending on how these and other assumptions are
determined and specified, summary health measures have been criticized
as being ageist or not ageist enough, as discriminating unfairly
against people with disabilities, as failing to capture the moral
uniqueness of life-saving, as treating as commensurable qualitatively
different losses and benefits, and as failing to take adequate account
of the claims of those who are most disadvantaged (Brock 2002; Daniels
2008; Kappel & Sandoe 1992; Nord 2005; Powers & Faden 2006;
Ubel 1999; Williams 2001; Whitehead & Ali 2010; Soares 2012).

Because formal methods and summary measures do not reflect these and
other considerations of justice, one widely recognized view is that
formal methods should be used solely as aids in public health policy
and not as determinative in their own right (Lipscomb, Drummond,
Fryback, Gold, & Revicki 2009). That said, there is a powerful
bias in favor of quantification and the empirical in public health
policy. Thus, there is the risk that the findings emerging from these
formal analyses will have determinative influence in policy
circles. One response to this risk has been to empiricize moral
considerations by, for example, measuring and aggregating the value
preferences of the public about moral tradeoffs such as prioritizing
by age or life-saving potential (Mason, Baker & Donaldson 2011;
Baker et al. 2008; Menzel et al. 1999; Nord
1999). These aggregated preferences or other approaches to quantifying
equity considerations can then be used in various ways to structure
policy guidance. For example, they can be transformed into weights
intended to incorporate moral values directly into the structure of
the formal methodology, a move that continues to attract considerable
interest (Johri & Norheim 2012) but that is open to criticism on
methodological as well as substantive grounds. Moves of this sort may
obscure controversial moral considerations from public view and
deliberation, undermining democratic values and political
legitimacy. An important role for public health ethics is to continue
to look critically at both the role and specific methods of economic
and decision theory strategies for establishing priorities and
regulatory standards in public health, recognizing that considerations
of cost-benefit and efficiency are essential to public health
programming and policy, and at alternative approaches for
incorporating equity considerations in priority setting and regulatory
decision-making (Cookson, Drummond & Weatherly 2009; Global Health
Priorities 2014 (Other Internet Resources); NICE International
2014 (Other Internet Resources)).

Just as in the economic, environmental, political and security arenas,
it has become increasingly difficult to discuss ethical issues in public health without
considering questions of justice, rights and responsibilities beyond borders. What duties do the more fortunate, wealthy, or
developed nations owe to promote or protect public health in more
impoverished, less developed countries or localities? What
interventions are justified and how should they be undertaken so as
not to breach respect for national sovereignty? And how should they be
undertaken so that they also create lasting improvements in health
infrastructures abroad, and not just a temporary external solution
that leaves another vacuum in its wake? The recent outbreak of Ebola in west Africa illustrates both the factually
interconnected, global nature of public health and the normative
reasons for considering public health a matter of global concern.

Three types of reasons can be advanced in favor of viewing public
health as transcending national boundaries: self-interest;
humanitarian considerations; and justice, rights and duties (Wolff
2012). The recent Ebola crisis again provides a helpful
illustration. The most common argument publicly advanced for assisting countries affected by the outbreak is that
addressing the crisis in West Africa is critical to our own health and
well-being in the developed world, as evidenced by the few
well-publicized cases of Ebola in the United States. Because diseases
are not constrained by national boundaries, we are at risk unless we
provide sufficient resources to contain and eradicate Ebola in
Africa. Thus, we should always consider public health a global matter
and should work to shore up health infrastructures and resources
abroad in order to avoid negative consequences in our own
backyards.

The next most common reason advanced is a humanitarian one: that we
should provide resources to care for victims of Ebola abroad because
it would be wrong to stand by and allow others to suffer in a crisis
when we have the resources to help. Under this framework, we have
positive duties to help those in desperate circumstances, and those
positive duties can sometimes transcend borders. On this view,
anything we do to promote public health abroad is essentially a
charitable action.

Far less common in public and academic discussions of Ebola is the
third view: that Ebola-stricken communities have a claim in justice
against the world's wealthy countries and persons for the resources
necessary to not only contain the current epidemic but also prevent
future ones. Under this view, everyone has a right to health and the
responsibility for the realization of that right crosses national
boundaries, at least when nations cannot or will not secure it for
their own citizens. On one of the most compelling arguments for this
view, we all are responsible for institutional structures that
contribute to and exacerbate unjust global inequalities, including
global health inequalities. Consequently, we have a duty to ensure
that the effects of these inequalities are mitigated, by providing
resources to resolve crises and also by helping to build effective
public health infrastructures in impoverished countries so that crises
can be averted in the future. Failing to do so is an injustice and not
merely a failure to act charitably or in accordance with humanitarian
obligations.[17]
Ultimately, that is why we cannot escape responsibility for
intervening when something like an Ebola outbreak occurs, even if
concerns about disease transmission and humanitarian sentiments did
not hold sway. One of the most difficult unanswered questions of this
line of reasoning, however, is assignment of responsibility. Who has
the responsibility to realize the right to health, and how can that
responsibility be operationalized? This remains a pressing but
under-addressed question in global public health ethics (Millum &
Emanuel 2012; Tasioulas & Vayena 2014; Tasioulas & Vayena
2015).

As was emphasized in Section 1, public health is and ought to be about
much more than simply medical care and classic public health
interventions. This observation naturally extends to the international
arena. Improving the health of the world's poor is indelibly tied to
economic, social, educational, and environmental improvements as well,
and health-related justice claims are also not easily separable from
justice claims that arise in those other contexts. The mere fact that
there are people who live in such poverty and deprivation that they
and their children die of starvation and the simplest infection should
be a sufficient indicator that there is something seriously wrong with
global institutional schemes, and that a justice-based obligation to
remedy that situation, both from a public health point of view and
more broadly, exists (Pogge 2008). How exactly to characterize and operationalize
that obligation remains the single biggest challenge for public health
ethics, and for global justice.

Brock, D. W., 2002, “Priority to the Worse Off in
Health-Care Resource Prioritization,” in Medicine and Social
Justice: Essays on the Distribution of Health Care, R. Rhodes,
M. Battin, and A. Silvers (eds.), New York: Oxford University Press,
pp. 362–372.

Hunt, P., and UN Economic and Social Council, 2004, Report of
the Special Rapporteur on the Right of Everyone to the Enjoyment of
the Highest Attainable Standard of Physical and Mental Health, Paul
Hunt, Publication No. E/CN.4/2005/51.

Schwappach, D. L. B., 2007, “The Economic Evaluation of
Prevention–Let's Talk about Values and the Case of
Discounting,” International Journal of Public Health,
52 (6): 335—336.

Shebaya, S., A. Sutherland, O. Levine, and R. Faden, 2010,
“Alternatives to National Average Income Data as Eligibility
Criteria for International Subsidies: A Social Justice
Perspective,” Developing World Bioethics, 10 (3):
141–149.